It's been a very busy seven days. Pretty much, all football, all concussions, all the time.

It began with a trip to Washington, D.C. to participate in last Friday's Aspen Institute roundtable on the future of youth and high school football, and back home.

Saturday and Sunday were spent getting the trailer for the new MomsTEAM football documentary, The Smartest Team, uploaded to a new website.

On Monday morning, after sharing my thoughts on Aspen, I turned my attention to preparing for a quick trip to Austin, Texas on Wednesday, where I was the after-dinner speaker at the end of a symposium on concussions put on by Core Health Systems.

Yesterday, I returned to Boston just in time to attend a lecture by NFL Commissioner Roger Goodell on football safety at the Harvard School of Public Health.

Today (it's Friday, right?), I am finally back at my desk trying to make sense of it all, including catching up on everything that has been written about the Aspen Institute roundtable and on reports about the way in which the concussions suffered by three NFL quarterbacks on Sunday were handled.

One of the Aspen and NFL concussion post-mortems I found particularly provocative was by Mike Wise, a columnist for The Washington Post.While I am not prone to writing in the somewhat snarky and definitly sarcastic tone Wise employed in his Tuesday column, and although he seemed to mostly align himself with the group at Aspen - led by Dr. Bob Cantu - that views football as too dangerous to be played before the age of 14 (a position with which I respectfully disagree), I did find myself agreeing with what seemed to be his main point: that whatever measures are instituted to protect player safety will get us nowhere if the culture on NFL fields (and by extension, the high school, middle school, and youth gridiron) doesn't change. If the long-since discredited language of "shake it off'" and "getting dinged" persists; if players aren't willing to self-report concussion symptoms; and, when on rare occasion they actually do, the coaches and medical personnel on the sideline don't take a lot more cautious approach in concussion management and pay more than lip service to the mantra of "When in doubt, sit them out," well, then, football may be in for a world of hurt.

In reading reports about how the concussion suffered by San Francisco 49er Alex Smith was handled, or, in the view of many, including Wise, mishandled, I was particularly struck by remarks attributed to Coach Jim Harbaugh as to why he allowed his quarterback Alex Smith to take six more snaps (ending, amazingly, in a touchdown pass) after admitting that he was experiencing blurred vision from a head-rattling hit on a quarterback sneak. "He felt [the blurred vision] would go away. He came over to the sideline and sat down and felt it would go away, and it didn't," said Harbaugh. "He told me he had blurred vision, and that's when we made the move [to sit him out for the remainder of the game]."

The times they aren't a-changin'

So let me get this straight: coach Harbaugh allowed Smith to keep playing with a clear symptom of concussion in the hope that his blurred vision would go away. Trouble is that, even under the three concussion grading systems in most common use in the 1990's and early 2000's (Dr. Bob Cantu's 2001 so-called "evidence-based" guidelines,1 the 1991 Colorado Medical Society (CMS) guidleines,2 and the 1997 American Academy of Neurology (AAN)3 guidelines) - all of which have long since gone the way of the dodo, by the way - and even if Smith's blurred vision had cleared up in less than 15 minutes, which, as it turned out, it didn't, he still would have been considered to have sustained a Grade 1 or mild concussion. That concussion shouldhave ruled out any return to play last Sunday, not just while he was still experiencing symptoms, but even if they had cleared up. His return to play would have been prohibited by law in the 41 states and the District of Columbia that have put in place - most at the urging and with the support of the NFL - of so-called Zackery Lystedt laws.

Clearly, Harbaugh's mindset is still the rule not the exception, shared not only by current players and coaches, but former players sitting in the broadcast booth. As Wise notes in his column, when Bear quarterback Jay Cutler went down after a helmet-to-helmet blow and yet stayed in the game against the Houston Texans (for a photograph of Cutler's Bears teammates helping their stunned and groggy QB to his feet after the hit, click here), NBC analyst Cris Collinsworth "paid him homage, calling Cutler, 'a real Bears quarterback," and "added that a review of the play would give Cutler a chance to 'clear the cobwebs' before action resumed."

In other words, it was perfectly okay, in the view of Collinsworth, and Harbaugh, and in the macho culture of football, from Pop Warner to the NFL, for a player to suffer a concussion, but, as long as the "cobwebs" (e.g. confusional state) or the blurred vision (a symptom of concussion experienced by 37.5% of concussed high school athletes in a recent study) cleared up, it is somehow okay to send the player right back onto the field.

News flash: It is NOT okay! To Wise, the "only way real change happens is if Jim Harbaugh doesn't leave Alex Smith in that game for six more plays; if Cris Collinsworth skewers the Bears' medical team for not checking on a groggy Jay Cutler; if Ray Lewis tells kids, via a PSA, why hard hits are okay and headhunting isn't; and, yes, if Drew Brees, a son of football-made Texas, has the guts to tell America his kid isn't playing tackle football before age 14."

I couldn't agree more, even on Wise's last point about Drew Brees. My position has consistently been and continues to be that it is up to parents to make decisions about their own kids' safety, and that the best thing I, MomsTEAM, the CDC, concussion experts, coaches, athletic trainers, and national governing bodies for football, from Pop Warner to USA Football to the NFL, can do is to (a) continue to do what we can and are doing doing to make the game safer (and that there remains a great deal of work to be done in this area is undeniable); and (b) provide accurate, objective information about the risks so that such decision is an informed one, not one driven by fear.

Biggest challenge

Which brings me to Roger Goodell's lecture yesterday at the Harvard School of Public Health. As the Twittersphere and today's Boston Globe reported, and as I was glad to make it back to Boston to hear him say in person, Goodell recognized that changing the culture of the NFL was not only his most important mission as commissioner but also the "biggest challenge" the league, and by extension, football at every level, faces. Goodell acknowledged that the culture of silence is alive and well; that too many players still hide concussions, and have a "play through, rather than a play safe mentality."

But, as one who who believes, like an increasing number of concussion experts, that the best way to increase the chances that a concussion will be identified immediately after injury is to utilize a technological "end-around" the problem of chronic under-reporting by players, I was also heartened to hear Commissioner Goodell talk about how the league is testing the use of accelerometers (e.g. hit sensors) in helmets and even in shoulder pads, not to replace self-reporting of symptoms by players or detection of concussion signs by sideline personnel or in the booth, but as another "tool in the concussion toolbox" or another pair of eyes.

If I have learned anything over the past twelve years of following the advances in our knowledge of concussion, both in terms of reducing the risk and in terms of better identification and post-concussion management and return to play, it is that an "all-of-the-above" strategy is the one that we need to employ because it has the best chance of making the game safer.

3. American Academy of Neurology. Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1997;48(3):581-585.